Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 30-06: Sexually Transmitted Diseases + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ All sexually transmitted diseases (STDs) have subclinical or latent periods, and patients may be asymptomatic Simultaneous infection with several organisms is common All patients who seek STD testing should be screened for syphilis and HIV Partner notification and treatment are important to prevent further transmission and reinfection in the index case +++ General Considerations ++ The most common sexually transmitted diseases (STDs) are Gonorrhea Syphilis Condyloma acuminatum Chlamydial genital infections Herpesvirus genital infections Trichomonas vaginitis Chancroid Granuloma inguinale Scabies Louse infestation Shigellosis, hepatitis A, B, and C, amebiasis, giardiasis, cryptosporidiosis, salmonellosis, and campylobacteriosis may also be transmitted by sexual (oral–anal) contact, especially in men who have sex with men Bacterial vaginosis may be sexually transmitted among women who have sex with women Homosexual contact and increasing, bidirectional heterosexual transmission are the typical methods of transmission of HIV Ebola virus and Zika virus have both been associated with sexual transmission +++ Sexual assault ++ Victims of assault have a high baseline rate of infection Neisseria gonorrhoeae, 6% Chlamydia trachomatis, 10% Trichomonas vaginalis, 15% Bacterial vaginosis, 34% The risk of acquiring infection as a result of the assault is significant but is often lower than the preexisting rate N gonorrhoeae, 6–12% C trachomatis, 4–17% T vaginalis, 12% Syphilis, 0.5–3% Bacterial vaginosis, 19% The likelihood of HIV transmission from vaginal or anal receptive intercourse when the source is known to be HIV positive is 1–5 per 1000, respectively + Clinical Findings Download Section PDF Listen +++ +++ Symptoms and Signs ++ See individual diseases + Diagnosis Download Section PDF Listen +++ +++ Laboratory Tests ++ Simultaneous infection by several different agents is common Laboratory examinations are of particular importance in the diagnosis of asymptomatic patients during the subclinical or latent phases of STDs All patients who seek STD testing should also undergo routine testing for HIV +++ Sexual assault ++ Victims should be evaluated within 24 h after the assault and cultures or nucleic acid amplification tests for N gonorrhoeae and C trachomatis should be performed Vaginal secretions are obtained for Trichomonas wet mount and culture, or point-of-care testing If a discharge is present, if there is itching, or if secretions are malodorous, a wet mount should be examined for Candida and bacterial vaginosis A blood sample should be obtained for immediate serologic testing for syphilis, hepatitis B, and HIV + Treatment Download Section PDF Listen +++ +++ Medications +++ Prophylactic therapy ++ The usefulness of prophylactic therapy for victims of sexual assault is controversial Prophylactic therapy may include postexposure hepatitis B vaccination without hepatitis B immune globulin; postexposure prophylaxis (PEP) of HIV; treatment for chlamydial, gonorrheal, or trichomonal infection; and emergency contraception Testing should be repeated only if the victim has symptoms If the status of the source is not known, and the victim presents within 72 hours of the assault, no firm recommendations can be made and the decision to treat is case-by-case If the patient seeks care > 72 hours after the assault, prophylaxis is not recommended +++ Therapeutic Procedures ++ As a rule, sexual partners should be treated simultaneously to avoid prompt reinfection Prompt treatment of contacts is facilitated by giving antibiotics to the index case to distribute to contacts and has been shown to prevent further transmission + Outcome Download Section PDF Listen +++ +++ Follow-Up ++ Follow-up examination for STD after an assault should be repeated within 1–2 weeks, since concentrations of infecting organisms may not have been sufficient to produce a positive test result at the time of initial examination If prophylactic treatment was given, tests should be repeated only if the victim has symptoms If prophylaxis was not administered, the victim should be seen in 1 week so that any positive tests can be treated Follow-up serologic testing for syphilis and HIV infection should be performed in 6, 12, and 24 weeks if the initial tests are negative +++ Prevention ++ Early initiation of antiretroviral therapy in HIV-infected individuals can prevent HIV acquisition in an uninfected sex partner Preexposure prophylaxis with a once-daily pill containing tenofovir plus emtricitabine has been shown to be effective in preventing HIV infection among high-risk men who have sex with men, heterosexual women and men, transgender women, and persons who inject drugs +++ When to Refer ++ Patients with a new diagnosis of HIV Patients with persistent, refractory or recurrent STDs, particularly when drug resistance is suspected + References Download Section PDF Listen +++ + +Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2018. 2019 Aug 27. https://www.cdc.gov/std/stats18/ + +Chou R et al. Preexposure prophylaxis for the prevention of HIV infection: evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2019 Jun 11;321(22):2214–30. [PubMed: 31184746] + +Goldstein RH et al. Being PrEPared—Preexposure prophylaxis and HIV disparities. N Engl J Med. 2018 Oct 4;379(14):1293–5. [PubMed: 30230965] + +Horner PJ et al. Mycoplasma genitalium infection in men. J Infect Dis. 2017 Jul 15;216(Suppl 2):S396–405. [PubMed: 28838074] + +Labhardt ND et al. Effect of offering same-day ART vs usual health facility referral during home-based HIV testing on linkage to care and viral suppression among adults with HIV in Lesotho: the CASCADE randomized clinical Trial. JAMA. 2018 Mar 20;319(11):1103–12. [PubMed: 29509839] + +Lefebvre B et al. Ceftriaxone-resistant Neisseria gonorrhoeae, Canada, 2017. Emerg Infect Dis. 2018 Feb;24(2):381–3. [PubMed: 29131780] + +Lin JS et al. Screening for syphilis infection in pregnant women: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2018 Sep 4;320(9):918–25. [PubMed: 30193282] + +MacGowan RJ et al. Effect of internet-distributed HIV self-tests on HIV diagnosis and behavioral outcomes in men who have sex with men: a randomized clinical trial. JAMA Intern Med. 2019 Nov 18;180(1):117–25. [PubMed: 31738378] + +Marcus JL et al. Risk compensation and clinical decision making—the case of HIV preexposure prophylaxis. N Engl J Med. 2019 Feb 7;380(6):510–2. [PubMed: 30726699] + +Price JC et al. Sexually acquired hepatitis C infection in HIV-uninfected men who have sex with men using pre-exposure prophylaxis against HIV. J Infect Dis. 2019 Apr 16;219(9):1373–76. [PubMed: 30462305] + +Sonawane K et al. Oral human papillomavirus infection: differences in prevalence between sexes and concordance with genital human papillomavirus infection, NHANES 2011 to 2014. Ann Intern Med. 2017 Nov 21;167(10):714–24. [PubMed: 29049523] + +Unemo M et al. Sexually transmitted infections: challenges ahead. Lancet Infect Dis. 2017 Aug;17(8):e235–79. [PubMed: 28701272] + +Wiesenfeld HC. Screening for Chlamydia trachomatis infections in women. N Engl J Med. 2017 Feb 23;376(8):765–73. [PubMed: 28225683]